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II ii �+L <br /> 4 i l���. SAAN JOAQUIN LOCAL HEALTH DISTRICT <br /> FOR OFFICI USE: 1601 E. Hazelton Ave. , Stockton, Calif. <br /> Telephone: (209) 466-6781 <br /> i <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit No-7 <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued <br /> (Complete In Triplicate) <br /> Application;; is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or inst1all the work herein described. This application is made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. I <br /> JOB ADDRESS;VLOCATION CENSUS TRACT <br /> Owner's Name Phone <br /> it E <br /> Address I City <br /> Contrac tors Name License 4jhone <br /> i <br /> TYPE OF WORK (Check) : NEW WELL / / DEEPEN / / RECONDITION DESTRUCTION DESTRUCTION /_ <br /> PUMP INSTALLATION / / PUMP REPAIR / / PUMP REPLACEMENT <br /> Other / / <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE'PIT OTHER <br /> j PROPERTY LINE -- PRIVATE DOMESTIC WELL PUBLIC DOMESTIC WELL <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia.- 'of Well Excavation \� <br /> Domestic/private Drilled Dia. 'of Well Casing <br /> Domestic/public Driven Gauge of Casing t \ _ <br /> Irrigation Gravel Pack Depth of Grout Seal <br /> € Cathadic Protection Rotary Type of Grout <br /> Disposal. Other Other Information <br /> Geophysical Surface Seal Installed By: r <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump / H.P. <br /> [PUMP REPLACEMENT: State Work Done <br /> PUMP -.REPAIR: / / State WorkDone <br /> F � <br /> �DES•TRUCTION OF WELL: Well Diameter Approximate Depth <br /> Describe Material and Procedure <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California pertaining to or regulating well "construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District <br /> WELL DRILLERS REPORT of the well and notify them before putting the..wel,l in use.. The above <br /> information is true to the best of my. knowledge and belief. I WILL CALL FOR A GROUT INSPECTI <br /> ,PRIOR TO G . UTING AND A FINAL I SPECTIO . JA <br /> SIGNED r TITLE _ <br /> w ( RAW PLOT PLAN ON REVERSE SIDE) l <br /> FOR DEPARTMENT USE ONLY <br /> PHASE I c <br /> APPLICATION ACCEPTED BY DATE O- 30-77 <br /> ADDITIONAL, COMMENTS: <br /> PHASE II GROUT INSPECTION PHAS III/FINAL INSPEC ION <br /> INSPECTIOM BY DATE INSPECTION BY DATE �} <br /> , 1177 m2M <br /> R H 1 L 96 Rasr_ 1-71L <br />